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* 1. Tax ID:

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* 2. Group NPI:

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* 3. Business or Group Practice Name:

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* 4. First Name:

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* 5. Last Name:

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* 6. Job Title:

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* 7. Are you a Key Contact Person?
A Key Contact Person is a person in a position of authority capable of making operational decisions, and is responsible for ensuring operational and/or payment system information from Arizona Complete Health is distributed as needed at their place of business.

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* 8. Email:

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* 9. Direct Phone Number:

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* 10. Business Phone Number:

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* 11. Business Fax Number:

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* 12. Business Mailing Address 1:

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* 13. Business Mailing Address City:

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* 14. Business Mailing Address State (please enter in two-letter format):

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* 15. Business Mailing Address Zip Code:

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* 16. Counties served:
Your business must have either a local office, travel to provide service within that county, or otherwise serve this county via remote options.

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* 17. For which lines of business do you wish to receive information?

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* 18. Provider Type:
Please select all that apply to your business or provider group as a whole

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* 19. Provider Specialty:
Please enter all that apply to, or are offered by, your business or provider group as a whole.

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